Tri Cities Rehabilitation and Healthcare Center

Inspectors wroteBased on interview, record review, and review of the facility's policy, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice and their comprehensive person-centered care plan for 1 of 5 sampled residents (Resident (R)1). The facility admitted R1 on [DATE], with a diagnosis of diabetes mellitus, with orders obtained for blood glucose monitoring (BGM) and insulin. The facility documented administration of R1's insulin; however, there was no documented evidence of the BGM for the dates of 07/02-04/2026. Per the facility's documentation, R1 was sent to the hospital on [DATE] for hyperglycemia. Review of the hospital documentation revealed R1 presented with a blood sugar reading of 672 with moderate ketones (moderate to large amounts of ketones could lead to a life-threatening condition called ketoacidosis).

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to serve meals in accordance with the established menu and required portion sizes, which had the potential to affect all residents consuming their meals from the facility's kitchen.

Inspectors wroteBased on observation, interview, record review, and review of facility policy, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 12 of 22 sampled residents.

Inspectors wroteBased on observation, interview, and review of facility policy, the facility failed to ensure beverages were served in a palatable manner, to include temperature and taste for 6 out of 22 sampled residents (Resident (R)27, R33, R23, R35, R51, and R40), and had the potential to affect all residents consuming hot beverages from the facility's kitchen.

Inspectors wroteBased on document review, interview, and policy review, the facility failed to ensure the dietary department was managed by a qualified director of food and nutrition services with the potential to affect 67 of 69 residents living at the facility.

Inspectors wroteBased on observation, menu review, interview, and facility policy review, the facility failed to ensure the menus and menu extensions were followed which included providing appropriate approved food substitutions, ensuring recipes were followed, and proper scoop sizes were utilized for 67 out of 69 residents residing in the facility. This failure had the potential for residents to lose weight.

Inspectors wroteBased on observation, document review, interview, and policy review the facility failed to ensure food items in the kitchen and storage areas were dated and labeled, food temperature logs were completed on a consistent manner, and utensils were not stored in ready to eat food for 67 out of 69 residents. This failure had the potential to lead to food-borne illnesses and cross contamination.

Inspectors wroteBased on observation and interview, the facility failed to ensure garbage was properly disposed of and contained; with the potential to affect 69 census residents and staff in the facility. This failure had the potential to attract pests.

Inspectors wroteBased on observation and interviews, the facility failed to ensure staff donned (put on) personal protective equipment (PPE) prior to cleaning the outside of two facility dumpsters. This had the potential for staff, who lacked proper PPE, to carry bacteria into the facility and possibly contaminate areas in which residents live for 69 census residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure six of six residents (Resident (R) 3, R19, R46, R56, R1, and R8) reviewed for care conferences out of a sample of 23 residents contained evidence the resident and/or her representative participated in the development or revision of their care plans. This failure would affect all residents and/or representatives who were scheduled for quarterly care plan meetings.

Inspectors wroteBased on record review, interviews, and review of facility policy, the facility failed to ensure two out of three residents (Resident (R) 15 and R48) reviewed for abuse/neglect were free from physical abuse of 23 sample residents. R15 and R48 got into a physical altercation in the facility's smoking area and both residents were injured related to the altercation. The facility's failure to ensure measures were in place to prevent the incident of resident-to-resident abuse between R15 and R48 created the potential for both residents to continue to be abused leading to potential physical and/or psychosocial harm to the residents.

Inspectors wroteBased on observations, record review, interviews, and facility policy review, the facility failed to ensure one of four residents (Resident (R) 38) reviewed for weight/nutrition was provided with recommended and physician prescribed interventions to prevent weight loss of 23 sample residents. This failure created the potential for R38 to experience further weight loss.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure that a trauma survivor received trauma-informed, culturally competent care accounting for resident's experiences and preferences to avoid triggers (psychological stimulus that prompts recall of a previous traumatic event, even if the stimulus itself is not traumatic or frightening) leading to potential re-traumatization for one of three residents (Resident (R) 56) reviewed for mood/behavior of 23 sample residents. The failure had the potential to affect residents with a diagnosis of post-traumatic stress disorder which could interfere with residents' quality of life.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure one of four residents (Resident (R) 36) reviewed for accidents was assessed for her use of side rails, had a care plan in place for use of the rails, and had an informed consent for the use of side rails out of 23 sample residents. This failure created the potential for the resident to be injured related to potentially unnecessary side rails installed and in use on her bed.

Inspectors wroteBased on observation, record review, interviews, and facility policy review, the facility failed to ensure a medication error rate of less than 5% with two errors, involving two of five residents (Residents (R) 46 and R73), conducted out of a total of 28 opportunities for error, resulting in a 7.14% error rate out of 23 sample residents. R46 was not prompted to rinse his mouth after the administration of an inhaled steroid medication and the insulin pen was not left inserted in R73's subcutaneous (fatty) tissue for the required amount of time to ensure full absorption of the insulin. These failures created the potential for residents to experience negative physical impact related to the administration of their medications.

Inspectors wroteBased on interview, record review, and facility policy review, it was determined the facility failed to ensure the accuracy of the resident's medical record for one (1) of nineteen (19) sampled residents (Resident #3). Resident #3 had a physician's order dated 03/28/19, for the resident's code status to be Do Not Resuscitate (DNR). However, the physician monthly order sheets for April 2019 through July 2019 revealed the orders stated the resident was to be a Full Code.